The girl s father asserts that it is his right to decide what happens to his daughter.

Patient Challenges p. 51 PATIENT CHALLENGES A 16-year-old female with diabetes mellitus and anorexia nervosa is admitted to the ICU following an attempted suicide with an overdose of benzodiazepines, tricyclic antidepressants and calcium antagonists. She has a varying level of consciousness, at times drowsy, at times agitated. She has been admitted to the hospital on three previous occasions following suicide attempts. Her parents arrive; her father is aggressive and demands to take his daughter to another hospital due to his mistrust of your institution. Links to PACT module on Major intoxication PACT module on Altered consciousness Q. How should you handle the father s demands? A. Acknowledge the father s feelings of powerlessness and reassure him that you are committed to providing the best possible care for his daughter. Explain that she needs the close supervision that is available only in an ICU, and that her condition is serious, so moving her would be unwise. Handling differences of opinion Difficult relatives Communication techniques: attentive listening, asking questions, paraphrasing, reflecting, explaining The girl s father asserts that it is his right to decide what happens to his daughter. Q. Explain the rights of parents according to the laws or ethical principles (beneficence or autonomy) underlying the medical approach to the patient in the relevant country A. A system emphasising beneficence might assume that physicians will make most decisions, based on the patient s best interests, and that family members may be informed rather than involved. In a system emphasising autonomy, physicians are more likely to include families in the decision-making process. Involving the family in decision-making PACT module on Ethics You explain to the father that his daughter has a right to care which is most appropriate at the time. He scowls, but agrees. Soon afterwards, however, you observe that the daughter becomes very agitated whenever her father is around. Q. How should you determine the patient s needs in this situation? A. Suggest that the parents take a break in the hospital cafeteria. Ask the patient how she feels about having her parents around. Meeting the patient s needs

Patient Challenges p. 52 Shortly after the parents return to the room, the patient develops severe cardiac arrhythmias and acute hypotension. You decide to try an electrocardioversion. You again ask the parents to leave. Q. What are reasons for and against allowing family members to witness resuscitation? A. There is no general consensus as to whether relatives should be present during specific interventions in the ICU or during CPR. Studies on the presence of relatives during resuscitation show that most family members strongly favour being given the option to remain, and that witnessing resuscitation is a positive rather than a negative experience for them. Although the majority of doctors and nurses oppose the practice, and a 2009 study found that family presence negatively affects staff performance, another study showed that allowing family members to remain can create a rapport between the family and the staff. In the present case, however, relations with the father are already difficult. Family presence during resuscitation Grice AS, Picton P, Deakin CD. Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units. Br J Anaesth 2003; 91(6): 820-824. PMID 14633752 The parents leave the room. The patient is successfully electrocardioverted but needs to be intubated due to worsening level of consciousness. The parents confront you in the hallway and ask what is going on. Q. When, how, and where will you inform them about your diagnosis and prognosis? A. Whenever possible, conferences with the family should be conducted in a private room with enough space and chairs for everyone to sit down. You should be careful not to promise that the patient will recover, and provide information about possible outcomes, both positive and negative. Bad news should be delivered in language that is simple and unambiguous. Meeting the patient s needs: Information What do families want and need to know? Where to talk with families Breaking bad news During the night the patient again has severe arrhythmias and develops ventricular fibrillation. She is again successfully resuscitated. The nurse responsible for the patient wants to talk with you about the ethical repercussions of repeatedly reviving a patient who obviously wants to die. Q. Why should you discuss the issue with the patient s nurse? Who else might you involve in the dialogue?

Patient Challenges p. 53 A. Involving members of the clinical staff in discussions promotes a good working environment. Inviting the nurse to communicate her concerns will send the message that she is part of the team and will help her deal with the emotional distress she is feeling. A discussion may offer you a new perspective on the patient. You can hold a quick meeting and invite any of the staff involved in the patient s care including the senior ICU nurse manager. A consultation with an ethicist or the hospital s ethics commission (if time allows and such arrangements exist) may be useful if opinions remain divergent. Working in a multidisciplinary team Promoting cooperation and collaboration When you come in to work the next morning you learn that, due to an error, the patient has received a much greater amount of insulin than intended and has suffered an episode of severe hypoglycaemia. She is deeply comatose. Even without her problems due to drug intoxication, you suspect that she has a poor prognosis as a result solely of hypoglycaemic brain damage. Q. How do you handle this situation? With whom do you discuss the error and what do you focus on? A. If your hospital has a protocol for handling serious errors, follow this. Inform the ICU senior clinician and clinical director. The hospital director, legal department, and communications department may also need to be informed. Talk to the people who were involved in the patient s care, and reconstruct the events. Record facts rather than emotional reactions. Do not place blame. Instead, use this as opportunity to discuss what went wrong and how to avoid such errors in the future. Dealing with problems Breaking bad news Q. What do you tell the parents now? A. Above all, be honest. Explain that a mistake was made. Outline the consequences it may have for their daughter. Apologise. If necessary, refer the parents to the hospital s ombudsman or equivalent. Most errors and systems errors require corrective action at an organisational level. Families may still take legal action in the event of disclosed negligent error, but failure to disclose, failure to apologise, and above all, failure to demonstrate contrition and corrective action for the future, will make the situation much worse for all participants. Handling errors in the ICU A 43-year-old female is admitted to the ICU because of subarachnoid haemorrhage. She is comatose, intubated and mechanically ventilated. While you are examining the patient, she suffers a significant fall in oxygen saturation. At the same time, the nurse tells you that the patient s husband is waiting anxiously outside the unit. Link to PACT module on Acute brain ischaemia

Patient Challenges p. 54 Q. What are your priorities and how do you proceed? A. Treating the acute fall in oxygen saturation is your first priority. Your second priority is to acknowledge the needs of the patient s husband. Ask the nurse to allow him into the room so that he sees his wife and the activity surrounding her. Depending on the policy of your ICU, you can allow him to stay in the room, or suggest that he makes himself comfortable in the waiting room. He should be told that his wife s condition is critical, and that when she is more stable you will speak to him. Explaining, checking understanding Providing information Involving the family in patient care When you have an opportunity, you introduce yourself to your patient s husband. You discover that he speaks a language you are unable to speak. Overcoming communication barriers Q. How do you deal with this situation? A. Assess whether the husband also understands your language, and if so, how much. If your hospital has a list of personnel with special knowledge of the language, make contact with that person. Is there another family member who can come to help translate? Do you have any printed materials in the husband s language, such as specially designed dictionaries or word lists? Make a special effort to speak in simple terms and to check whether he has really understood what you have said. Communicating effectively - What you can do Providing information Q. What should you communicate to the husband? A. His wife s status, including diagnosis, prognosis, and the next steps of treatment. Your role and the role of other team members directly involved in care of the patient. Basic information about your intensive care unit, if it is available in printed form. Checking understanding, explaining Providing information A few hours after admission to your ICU, the patient is still drowsy but haemodynamically stable. Angiography and coiling of an aneurysm of the anterior communicating artery have been successfully performed by the neuroradiologist. The patient is extubated during the night. During the morning report, the resident from the night shift tells you that the patient was alert during the last two hours. She is breathing spontaneously and has no haemodynamic compromise. She is afebrile and has no neurological focal deficits. Her pulse rate is in the normal range, and she has a normal arterial blood pressure. At later clinical review however, you see that the patient is rousable but confused.

Links to PACT module on Altered consciousness PACT module on Clinical examination Patient Challenges p. 55 Q. What changes can you make in your department s approach to rounds that will ensure that the important information is communicated? A. You can propose implementing an explicit approach to rounds requiring documentation of the status of each organ system. Is there a structured approach to handovers between teams and shifts? Consider including a flow chart for rounds in the resident s manual. Is the patient examined prior to rounds? Could the patient s condition have deteriorated in the interval between assessments? Is there a medical problem list? Is the resident aware of the patient s key problem? Is there a clear plan for the following 24 hours? Is there a clear long-term plan? Dodek PM, Raboud J. Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med 2003; 29:1584-1588. PMID 12898001 Profiting from rounds Handling errors in the ICU While you are standing at the patient s bedside the neurosurgeon enters the room, and without talking to the patient he triggers pain by squeezing her left toe. Q. What is your action? A. Having recently read the PACT module on Communication, you are aware that, even if a change in the clinical status of the patient is the main concern for the neurosurgeon, a more appropriate first action would be to greet both the patient and the team members present at the bedside. Addressing the group, you say something to the effect of: I just learned in PACT that Acknowledging patients Over the following two days the patient s clinical status fluctuates. Overall she remains confused but without focal neurological deficits. Transcranial Doppler ultrasonography does not show signs of cerebral vasospasm. On the third day the nurse calls you because of acute dilatation of the left pupil. You arrange for a cerebral computed tomography, which reveals rebleeding. She is sedated, intubated and ventilated for the procedure. The neurosurgeon arrives and claims that the bleeding is due to inappropriate management of blood pressure. Q. What factors influence how you will respond to the neurosurgeon s criticism? A. Your action depends on several factors. Is this the first time such a claim has been raised, or do you have frequent problems with such patients? Are interactions with this particular surgeon frequently difficult?

Patient Challenges p. 56 Promoting cooperation and collaboration Q. How do you respond? A. Postpone dealing with this issue until any clinical intervention required by the change in the patient s condition have been completed. Then discuss the facts with the neurosurgeon objectively. Remind him of the frequency of secondary bleeding in such patients. Link to PACT module on Acute brain ischaemia Four hours later the patient is polyuric. She does not show any motor response to pain, and many brainstem reflexes appear to be absent. None of her relatives are present, but the nurse says that the patient s husband phoned a few hours ago and was told that his wife was clinically stable. He asked to be informed of any change. With the help of an interpreter, you telephone the husband. Q. What do you communicate? A. Providing appropriate, timely information is essential. Through the interpreter, you tell him that his wife s clinical situation has markedly deteriorated and suggest that he come to the hospital as soon as possible. Several hours later, brain death is confirmed according to guidelines in your hospital and jurisdiction. In the meantime, the husband and two of the patient s four children have arrived at your unit and are at the bedside. Q. How do you break the news that your patient is brain dead? A. As a first step, you refer to your last contact with the relatives and explain that the patient s situation deteriorated quickly. Then, using simple language, explain that although everything possible was done, it has now been confirmed that the patient is brain dead, which means that her body is able to function only with the help of machines and her brain is no longer able to control what her body does. Answer any questions in an honest and direct way, and then allow the family members time to be alone. Remember that the grief process may include shock, desperation and confusion, a period of searching and denial, followed by anger and ultimately acceptance and reintegration. Breaking bad news Link to: PACT module on Ethics Blok GA, van Dalen J, Jager KJ, Ryan M, Wijnen RM, Wight C, et al. The European Donor Hospital Education Programme (EDHEP): addressing the training needs of doctors and nurses who break bad news, care for the bereaved, and request donation. Transpl Int 1999; 12: 161-167. PMID 10429952

Patient Challenges p. 57 Given the clinical course of the patient, organ donation should be considered. Until now, organ donation has not been discussed with the relatives of your patient. Q. When is the appropriate time to talk to the relatives about organ donation? A. First the family must be allowed to absorb the news that the patient has died. They should have time to be with their relative. Also, they should have the opportunity to meet with a member of the clergy if they wish to do so. However, there is limited time for these processes if organ donation is to remain a possibility. If you and the other caregivers feel that the family members have understood the death and that appropriate time has passed, you may again meet with them to discuss the issue of organ donation. Requesting organ donation PACT module on Organ donation and transplantation Several hours pass, and you feel that the family can be approached. Q. You will need a family meeting. Who should attend it, when and where should it be held, who should lead it, and what should be discussed? A. The meeting should be scheduled at the earliest time convenient for the family. It should be attended by the patient s husband and children, any other close family members identified by the husband, other ICU team members as needed e.g. nurse, clergy, social worker, as well as someone qualified to discuss organ donation. The meeting should be held in a private room and led by a senior physician. Use simple language, be patient, and show understanding. The family should be given ample time to ask questions and to discuss the issue of organ donation among themselves, as they need to reach a consensus on what the patient would have wished in this circumstance. Support their decision once it has been made. Nelson JE, Walker AS, Luhrs CA, Cortez TB, Pronovost PJ. Family meetings made simpler: a toolkit for the intensive care unit. J Crit Care 2009; 24(4):626.e7-14. PMID 19427757 On reflection, while working in the ICU you need to communicate with patients, family members, and co-workers. The adverse consequences of ineffective communication with patients and families include dissatisfaction with care; difficult behaviour; uninformed or no consent for procedures, research studies or organ donation. Ineffective communication with co-workers can result in errors, negative attitudes, bad working environment, a blame culture and failure to learn. Good communication has been shown to improve the process of patient care.